Chylothorax_,Extended_Treatment_Red.pptx

Chylothorax

1. Chylothorax - Overview Definition: Accumulation of lymphatic fluid (chyle) in the pleural space due to disruption or obstruction of the thoracic duct. Composition: Milky, odorless fluid rich in triglycerides, lymphocytes, and chylomicrons. Incidence: Rare but significant postoperative complication in thoracic and cardiac surgery.

2. Etiology & Pathophysiology Causes: - Iatrogenic (post cardiac/thoracic surgery, esophagectomy, trauma) - Malignancy (lymphoma) - Idiopathic (rare) Mechanism: - Injury or obstruction to thoracic duct → leakage of chyle into pleural space - Chyle loss → malnutrition, immunosuppression, electrolyte imbalance

3. Clinical Features & Diagnosis Clinical Features: - Dyspnea, chest fullness - Decreased breath sounds - Milky pleural drainage post-surgery Diagnostic Tests: - Pleural fluid triglycerides >110 mg/dL - Sudan III staining (chylomicrons) - CT / Lymphangiography for site localization

4. Conservative Management 1. Pleural Drainage: - Ensures lung re-expansion and prevents infection. 2. Dietary Management: - NPO initially → switch to Medium Chain Triglyceride (MCT) diet. - MCTs absorbed directly into the portal system, bypassing lymphatics. 3. Pharmacologic Therapy: - Octreotide or somatostatin: reduces intestinal chyle flow. - Duration: 5–10 days trial before considering surgery.

5. Nutritional Support & Monitoring • Total Parenteral Nutrition (TPN) indicated when chyle loss >1L/day. • Supplement with fat-soluble vitamins (A, D, E, K). • Monitor daily output, serum albumin, and electrolytes. • Reintroduction of diet once output <200 mL/day.

6. Surgical Management 1. Thoracic Duct Ligation: - Gold standard when conservative therapy fails after 5–7 days. - Approach: Right thoracotomy or VATS above right hemidiaphragm. 2. Thoracic Duct Embolization: - Interventional radiology technique using coils or glue. 3. Pleuroperitoneal Shunt: - Transfers chyle into peritoneal cavity for absorption. 4. Pleurodesis: - Chemical (talc) or mechanical methods to obliterate pleural space.

7. VATS & Minimally Invasive Techniques • Video-Assisted Thoracoscopic Surgery (VATS): - Preferred for visualization and duct ligation. • Advantages: - Less pain, shorter stay, faster recovery. • Intraoperative localization: - Preoperative ingestion of cream or olive oil to enhance chyle visualization.

8. Postoperative Care & Outcomes • Chest tube management: monitor output and character. • Gradual diet advancement under monitoring. • Monitor for recurrence or nutritional deficiencies. • Prognosis: Excellent if recognized early and treated promptly.

9. Recent Advances & Research • Lymphangiographic imaging to identify leak sites. • Role of lipiodol embolization and fibrin glue in duct closure. • Use of robotic-assisted thoracic surgery for duct ligation. • New pharmacologic therapies under research: sirolimus, propranolol.

10. Summary & Key Points • Early identification crucial to prevent morbidity. • Conservative therapy succeeds in up to 60% of cases. • Surgery indicated for persistent or high-output chylothorax. • Multidisciplinary approach improves outcome. • Reference Texts: - Shields TW. General Thoracic Surgery. - StatPearls: Chylothorax (2024). - Iowa Head & Neck Protocols.